RETINAL DETACHMENT Pathologist's Report

Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

RETINAL DETACHMENT 35r.9 Pathologist's Report Dr. E. S. Winter, pathologist to the County Hospital, Lincoln, reports as follows: The specimen, which is heart shaped, liver coloured and surrounded by a thin glistening capsule, measures rather over 2.5 cms. in length, 2.5 cms. in breadth and 1.5 cms. at its thickest part. On removing a small piece for sectioning, the contents seemed to consist of innumerable small spaces, separated by well-formed tissue and containing blood. Microscopically, the section shows irregular communicating spaces with walls lined with endothelial cells and filled with blood corpuscles. The specimen is a haemangeioma.

ABSTRACTS

I.-RETINAL DETACHMENT

Rubbrecht, R. (Bruges).-The closure of holes in the retina. (L'Obturation des D6chirures de la R&tine). Arch. d'Ophtal., March, 1930. In this paper Rubbrecht deals only with operative technique, leaving out of consideration the role of retinal tears in the patho- http://bjo.bmj.com/ genesis of detachment. After a tribute to Gonin as the pioneer of the treatment under discussion, he alludes to the difficulty often experienced in finding the hole in the detached retina; more than one examination may be necessary. The tear may be situated at the extreme periphery of the ophthalmoscopic field; it may be in a part of the retina which has become re-applied and distant from on October 1, 2021 by guest. Protected copyright. the actual detachment; it may be hidden by a fold of the retina and only discoverable when the patient has been recumbent for several days. Having found the hole it is necessary to localise it as exactly as possible, in order that the site may be indicated as nearly as is feasible on the external surface of the sclera. For this there are two essentials:-(1) to determine the meridian in which the tear lies, and (2) to calculate the distance between the lesion and the corneal limbus; or, as the author suggests, " to fix the longitude and latitude." Rubbrecht's -plan is as follows:-The patient is placed in a horizontal posture and looks directly upwards;' the examination is made of the upright image. In Fig. 1 the retinal tear is at D: the observer at A sees it projected on the edge of the pupil; this being dilated to its maximum, Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

3603 HE BRITISH JOURNAL OF OPHTHALMOLOGY the image of the tear appears to be a very short distance from the limbus, and the corresponding point on the limbus is marked with Chinese ink. TIhe observer then shifts his position to B and sees the image of the tear projected on the pupillary border directly opposite that already noted. A second mark is made at the limbus at

FIG. 1. http://bjo.bmj.com/ on October 1, 2021 by guest. Protected copyright.

FIG. 2. this point, and thus we have, indicated very accurately, a diameter of the cornea which forms part of the circle of longitude in which the retinal hole lies (Fig. 2). The next essential is to determine the meridian in which the incision is to lie. The simplest plan is to calculate in disc-diameters the distance between the tear and the ora serrata. This latter is not always visible and then it suffices to take the extreme point visible with the ophthalmoscope. This examination should be made with the patient lying down. The calculation should be made with all possible care, but absolute exactness is neither Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

RETINAL DETACHMENT 361 possible nor essential. As will be seen later, in the method here described, the intervention is not on one point but on a certain extent of a meridian, and this lessens notably the risk of-error. Having determined the distance of the retinal tear from the ora serrata it is necessary to ascertain its distance from the limbus. From the limbus to the ora serrata is reckoned as 8 mm. If, for example, the tear is found to be 3 disc-diameters from the ora serrata it should be 8 + 4-5 mm. = 12 mm. from the limbus. Rubbrecht states emphatically that these examinations and measurements are of prime importance; if necessary several days should be devoted to them. Thorough local anaesthesia having been induced by novocaine and adrenaline, the steps of the operation follow in definite order. http://bjo.bmj.com/

FIG. 3. A thread is inserted at the limbal ink-mark farthest from the site of the incision (Fig. 3). This thread is knotted at the end. Re- section of the external or internal rectus is then performed: this resection, which is purely temporary, is helpful as it enables the on October 1, 2021 by guest. Protected copyright. assistant to grip the globe firmly by the cut tendon and to rotate it sufficiently to expose the sclera for incision. Stitches are passed through the two parts of the muscle and these are brought together accurately immediately after the operation. The conjunctiva, and episcleral tissue, are incised parallel to the limbus on the side of the detachment. The area of sclerotic laid bare should measure at least 1 cm. antero-posteriorly. By means of a retractor the posterior edge of the conjunctival w6und is pulled backwards and a haemo- static applied carefully to the exposed surface of the sclera to obviate any interference with the further procedure, by bleeding. The thread already inserted in the episcleral tissue and retained by a knot now becomes a directing thread (" le fil conducteur "). It is brought across the cornea and passed through the second limbal Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

362 THE BRITISH JOURNAL OF OPHTHALMOLOGY ink-mark (Fig. 4) and carried onwards in the same line over the denuded sclera. This indicates the meridian in which the retinal tear lies, and an ink-mark is drawn on the sclera along the course of the.thread. The directing thread is now removed. Assuming now that the site of the tear has been measured as 14 mm. from the limbus, the incision is begun at a point 12mm. from the limbus and continued along the meridian shown by the ink line to a point 16 or 17 mm. from the limbus, thus having a length of 4 to 5 mm. The incision is made with a Graefe knife very cautiously, layer by

FIG. 4. layer, to avoid sudden penetration of the vitreous. The choroid is incised and the subretinal fluid allowed to escape. The galvano- cautery at a bright red heat is passed rapidly in the whole length of the incision. Rubbrecht prefers a sickle-shaped terminal: he does not attempt to plunge the terminal into the vitreous, and http://bjo.bmj.com/ indeed he disapproves of such a procedure. The application of the cautery occupies only a few seconds. The resected muscle and the conjunctiva having been sewn up, a bandage is applied over both eyes for 24 hours. The-patient is kept in bed for 8 days; atropine is applied to the operated eye once daily.

J. B. LAWFORD. on October 1, 2021 by guest. Protected copyright.

II.-REFRACTION

(i) Ferree, C. E., Rand, G. and Monroe, M. M.-Errors of refraction, age and sex in relation to the size of the form field and preliminary data for a diagnostic scale. Bulletin of the Johns Hopkins Hospital, Vol. XLV, p. 295, 1929. (1) Ferree and Rand, whose careful work on standardising the conditions for perimetry is well known, take up in the present article the variations in the form field with different individuals. The importance of such a study (in which they had the help of Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

REFRACTION 363 Monroe) is obvious, if perimetry is to be used as a means of diagnosis by revealing early changes in the field. " Previous writers on this subject seem to have been content to give the breadth of field in the principal meridians for the average case, or at most only a small range of variation on either side. The knowledge of what is an average field obviously contributes but little to the diagnosis of cases for which the help of perimetry is most needed. If a pathological condition is to be diagnosed in its incipiency, the border line between normal and pathological conditions must be located within reasonably narrow limits. For example, a given field may be much smaller than the average and still fall within the range of normal variation." The present study has been carried out to determine the range of variation of the form field for non-pathological eyes for a stimulus subtending a visual angle of one degree. The cases studied, two lhundred in number, were sampled to include as many as possible of the outstanding variables which are not pathological. Errors of refraction were found to be an important factor influen- cing the variability of results from individual to individual; in general the emmetropes and hypermetropes have wider fields than the myopes. Presbyopia, too, has an effect; under 40, age has no influence on the field, but the onset of presbyopia tends to make the field narrower. Sex would appear not to be a factor of sufficient importance to be taken into account in diagnosis. The authors have established a scale showing the range of variation of field

under the influenc6 of these variables; and also showing the dis- http://bjo.bmj.com/ tribution or frequency of occurrence of the different sizes of field in a typical non-pathological group. " Such a scale provides a means of placing each new case in the class or group to which it belongs, rated with regard to the distribution of normal cases, i.e., it constitutes a scale for use in the separation of pathological from non-pathological cases." ARNOLD SORSBY. on October 1, 2021 by guest. Protected copyright.

(2) Tron, Eugen (Leningrad).-Statistical research on variations in refraction. (Variationsstatistische Untersuchungen ueber Refraction). Arch. f. (Qbhthal., Vol. CXXII, p. 1. (2) Tron has studied the measurements of a series of 200 eyes, showing a refraction varying from + 7D. to - 25D., by means of the ophthalmophakometer, and his investigations on the variability of the dioptric elements of the eye show that all these elements (depth of the anterior chamber, thickness of the lens, radii of the refracting surfaces, the refractive power of the cornea, lens, and the whole eye) form a variational curve that exhibits a substantial agreement with the normal binominal curve. Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

364 THE BRITISH JOURNAL OF OPHT1HALMOLOGY The sole exception to this is the variational curve for the axial length, which is characterised by its great asymmetry and considerable height. These features disappear when all cases of myopia of - 6D. and over are excluded from the series, and the axial length then shows a curve corresponding with the binominal. The marked asymmetry and height of the curve for the axial length of the entire series of cases is due to the fact that it is to a certain extent made up of two curves: a normal variational curve for axial lengths of eyes between + 7D. and - 6D., and a second curve for cases of high myopia which takes an irregular course and is added on to the first. The fact that in eyes between + 7D. and - 6D. the axial lengths form a normal variational curve indicates that the different axial lengths of these eyes are merely links in a normal variational series. Hence it is impossible to accept the theory that an arrest of development is the cause of a short axial length in hypermetropia, or that the lengthening of the axis in myopia is due to cIose work and pathological factors. The refractive power of the lens is extremely variable, this variability, though little importance has been attached to it, being no less than that of the cornea. Hence any determination of the axial length in the living eye that only takes account of the corneal refraction and employs for the lens refraction the number for the schematic eye, thereby neglecting the normal variability of the lens refraction, is incorrect, as the author demonstrates in a table of examples. http://bjo.bmj.com/ In finding the relation between refraction and the different dioptric elements only the error of the particular ophthalmometric method employed was formerly considered, and the final conclusions were based on a comparison of the average values. The variational statistics, however, show that the average value of a series more or less variational empirically ascertained differs from on October 1, 2021 by guest. Protected copyright. the true average of that series because of the existence of the average error. The statistical and variational study of this series of eyes, taking into consideration the average error for every average value, brought out the fact that as regards the elements of the optical apparatus of the eye, with the exception of the axial length, no real differences can be found between emmetropia on the one hand and hypermetropia and myopia on the other. In the case of the axial length there are definite differences between the different types of refraction, and yet the variational limits in the axial length overlap to some extent in these types. Hence one can conclude that the axial length in eyes of different refraction may be the same. The calculation of the correlation-coefficient between refraction Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

GENERAL MEDICINE 365 and axial length for the entire series as well as for the different types of refraction brings out figures that are only slightly over 0 5. The fact that there is a positive correlation between refraction and axial length proves that the absolute length of the axis has by itself no definitive importance for the refraction. The analysis of the correlation between refraction and axial length on the one hand and the refractive power of the eye on the other, and the existence of only slight, and even negative, correlation between axial length and refractive power of the eye show that in the majority of cases the refraction depends neither on the absolute axial length nor on the refractive power of the eye, but on a combination of both these factors. THOS. SNOWBALL.

III.-GENERAL MEDICINE

(I) Friedenwald, H. and Friedenwald, J. S. (Baltimore).- The retinal blood vessels in hyperthyroidism and arteriosclerosis. Bull. Johns Hopkins Hospitail, Vol. XLV, p. 232, 1929. (1) H. and J. S. Friedenwald review our present knowledge of retinal arteriosclerosis and emphasise the difficulties and problems under consideration. They point out that even the significance of http://bjo.bmj.com/ such marked features as venous compression and altered light reflex on the arteries is still a matter of controversy, and the exact mechan- ism of such changes is a very much disputed problem. Their own contribution consists of an attempted classification of the retinal arteriosclerotic changes in relation to the general condition-a

classification based on the examination of two thousand cases. Their on October 1, 2021 by guest. Protected copyright. grouping is as follows: (1) Hypertension without retinal arteriosclerosis.-Hyperten- sion from any cause-including essential hyperpiesis-may exist without retinal sclerosis, though venous compression is seen more frequently in such patients than in normal individuals. In this connection it is of interest to note that the hypertension developing with old age is not associated in the early stages with changes indicative of retinal sclerosis. (2) Retinal arteriolar sclerosis and albuminuric retinitis.-The characteristic features of retinal arteriolar sclerosis are localised variations in the calibre, irregular tortuosity, and visibility of the walls of the terminal arterioles. These vessels can be studied better at the macula than at the periphery of the fundus. " In regard to the Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

366 'HE BRITISH JOURNAL OF OPHTHALMOLOGY tortuosity of these vessels a distinction must be made between the irregular tortuosity characteristic of vascular disease and the smooth sinuous tortuosity which is often seen in congested fundi in fever, eyestrain, etc." In addition to these arteriolar changes, the larger arteries usually show the characteristic features of sclerosis. The significance of this group lies in the fact that it must be regarded as the precursor of albuminuric retinitis, for all cases of this type that were followed up, ended as renal retinitis. Further- more all cases of renal retinitis show this arteriolar sclerosis, as can be seen even in those cases where oedema obscures the 'macular region, for in these cases the peripheral arterioles still show this change. Clinically, marked hypertension is present, and sooner or later a rapidly progressing chronic nephritis becomes manifest. Indeed all the well-known facts regarding age incidence, clinical associations and prognostic significance may be transferred bodily from the cases of albuminuric retinitis to the somewhat larger group of retinal arteriolar sclerosis." (3) Retinal arteriosclerosis with hypertension. Typically this occurs in old people with arteriosclerosis of the slow progressive type associated with hypertension. A characteristic feature is the reduction of the calibre of the whole arterial tree. " The relation of hypertension to the calibre is so close that the blood pressure can usually be estimated within quite narrow limits from the consideration of this sign alone. As a rough measure it may be said that when the arteries are reduced to approximately one half of their

normal calibre, the diastolic blood pressure will be found 110 mm. http://bjo.bmj.com/ or more." An important exception is the group of cases in which this retinal picture is associated with a low or normal blood pressure. In such cases the blood pressure has been lowered by some intercurrent disease, and cerebral thrombosis is a grave danger. Apart from the highly significant constriction of the lumen, the other changes of arteriosclerosis are of course also present, though on October 1, 2021 by guest. Protected copyright. the larger arteries rather than the terminal arterioles tend to be implicated. Any retinal changes present (haemorrhages, exudates) are scattered over the fundus and not concentrated at the macula. The authors warn against regarding constricted retinal arteries as a physiological change of senility. (4) Retinal arteriosclerosis without hypertension.-All the characteristics of retinal sclerosis are present, except that the arteries are full and tortuous. With such a retinal picture, not only is there no evidence of hypertension, but there is also no evidence of pre-existing hypertension that had been lowered by intercurrent disease. However, when this condition occurs in young people it is frequently only an intermediate stage going on to hypertension. (5) Syphilitic arteriosclerosis.-The authors h-old that when a Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

GENERAL MEDICINE 36' single branch shows evidence of arteriosclerosis, this points strongly to the lesion being syphilitic in origin. (6) Arteriosclerosis resulting from local causes.-Arterio- sclerosis is frequently the result of a purely local lesion, such as retinitis pigmentosa. The paper is well worth reading in full. ARNOLD SORSBY. (2) Igersheimer, J. (Frankfurt).-Affection of the optic nerve in malignant (vascular) sclerosis. (" Sehnervenerkrankung bei maligner sklerose.") Zeitschr. f. Augenheilk., Bd. CXIX, p. 47, 1929. (2) Igersheimer draws attention to isolated affections of the optic nerve quite apart from neuroretinitis, as not uncommon complications of arteriosclerosis. A full account is given of the clinical and post-mortem findings in a case of his concerning a man aged 49, who suddenly developed disturbances of vision found to be due to optic neuritis. Apart from an old history of apparently cured syphilis, general examination showed nothing of importance. Within less than a month the patient was completely blind, and a few days afterwards he died from cerebral haemorrhage. The diagnosis on the strength of the post-mortem examination (which revealed no syphilitic lesions) was malignant arteriosclerosis with hypertension. The retinae were hardly affected, but both optic nerves showed extensive degeneration, most marked near the disc; there was but http://bjo.bmj.com/ little evidence of inflammatory changes, and no possibility of the optic nerve atrophy being the result of these. In the author's opinion the atrophy of the nerve was the result of circulatory disturbances, possibly aided by arterial spasm. ARNOLD SORSBY. on October 1, 2021 by guest. Protected copyright. (3) Lange, Fritz (Munich).-Haemorrhages in the fundi in hypertension. Arch. of Ophthal., November, 1929. (3) Lange's paper opens with an interesting example of how a false conclusion can be made from statistical observations. In 75 per cent. of cases from the ophthalmic department, the haemorrhages were in the region of the fovea, while in cases from the medical clinic, the haemorrhages occurred only in the periphery. The author points out the obvious reason, viz., that macular haemorrhages cause a disturbance of vision which sends the patients to the ophthalmic department, but he also points out how easily a false conclusion could be formed about the area of predilection of haemorrhages if material from only one clinic were considered. The cases are divided into three groups: (a) Pure Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

368 THE BRITISH JOURNAL OF OPHTHALAMOLOGY hypertension, where the systolic and diastolic pressures are high, without there being any involvement of the kidneys or sclerosis of the peripheral arteries. (b) Pure arteriosclerosis, where the large and small arteries are sclerosed, but the blood pressure is normal or subnornmal. (c) Mixed forms, where there is arteriosclerosis with high blood pressure. Seven different clinical methods are given for differentiating the first two groups. One of these is to place a cuff round one arm and observe the blood pressure, cuffs are then placed round the other three limbs and inflated at the same time. In hypertension there is a great rise in blood pressure while in arteriosclerosis there is almost no change. Of the 60 cases examined, 57 had a systolic pressure over 160 mm. Hg. Fifteen of these were pure hyperpietics. The main change in the arteries was unevenness of calibre, and in two cases the contractions dis- appeared after some weeks, while in the remainder they were permanent. These unevennesses were usually present when the blood pressure exceeded 200 mm. Hg and were absent when it was under 180 mm. Hg. There was no instance of retinal haemorrhage recurring in a case of pure arteriosclerosis without hypertension. In cases of haemorrhage of other origin, such as syphilitic or diabetic, high blood pressure was present with few exceptions. The majority of the haemorrhages originate from the capillaries. F. A. W.-N.

IV.-BACTERIO LOGY http://bjo.bmj.com/ (i) Morax (Paris).-Le bacterium granulosis et le trachome. Rev. Internat. du Trachome, January, 1930. (1) The four Indians from whose conjunctiva Noguchi isolated his bacterium granulosis came from Albuquerque, New Mexico, whither journeys were made by several American surgeons, and on October 1, 2021 by guest. Protected copyright. by Lindner to confirm the diagnosis of trachoma. Therefore the trachoma studied by Noguchi does not differ from the trachoma found in Europe and in Egypt, at any rate clinically. The reviewer may note that Mayou, Brit. Jl. of Ophthal., 1928, and Wilson, Giza Lab. Reports, Egypt, 1928, remark on the different histological features of trachoma in America and trachoma in Europe or Egypt. TIhe principal difference is that the follicles in American-Indian trachoma consist almost entirely of epithelioid cells surrounded by a comparatively small ring of leucocytes. In European and Egyptian trachoma on the other hand the follicles are made up of lymphocytes and plasma cells, although there may be one or two epithelioid cells in old follicles. This is perhaps suggestive that there is more than one form of the disease. Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

BACTERIOLOGY 369 The bacterium granulosis was passed by Noguchi through a series of monkeys, causing the development of follicles. The resulting condition was looked upon by Noguchi and the American surgeons as of a trachomatous nature. Morax has carried out investigations on 11 cases of trachoma in exactly the same manner as described by Noguchi and with the same media but has been unable to detect an organism resembling the bacterium granulosis. He then obtained from the Rockefeller Institute three ampoules containing Noguchi's bacillus. He found this to be a small Gram- positive organism, employing the staining technique of the Pasteur Institute. This was very surprising as Noguchi had described the bacillus as being Gram-negative. Correspondence with the Rockefeller Institute showed that the period allowed for decolouration was much longer there than at the Pasteur Institute. As Morax considered that if the organism was Gram-positive it should be possible to find it in smears from trachomatous granula- tions he obtained from Algeria a large number of smears. In none of these cases was he able to find a Gram-positive bacillus resembling Noguchi's organism. Morax found that the organism obtained from the Rockefeller Institute was easy to cultivate on ordinary media, and did not easily die out. He sent some of the cultures of bacterium granulosis to Tunis where Weiss of St. Louis inoculated four persons, though without producing the slightest pathological reaction. The conclusion is that although Noguchi found a bacillus, not previously described, he did not find an organism causative of http://bjo.bmj.com/ trachoma. A. F. MACCALLAN.

(2) Cudnod and Roger Nataf (Tunis).-Ultra virus et trachonie. Rev. Internat. du Trachome, January, 1930. (2) Cudnod and Roger Nataf consider it advisable to suspend on October 1, 2021 by guest. Protected copyright. judgment as to the specificity of Noguchi's bacterium granulosis in the causation of trachoma. It is possible that this organism, though not itself causative, may perhaps be the carrier of an ultra- microscopic virus. We are reminded that Nicolle and Cu6nod have shown that the pathogenic principle of trachoma is contained in a filtrable virus. A. F. MACCALLAN (3) Ridley, Frederick.-Gas gangrene panophthalmitis. Trans. Ofhthal. Soc. U.K., Vol. XLIX, 1929. (3) Ridley gives a full account of a case of panophthalmitis due to the B.Welchii and of the bacteriological investigation by Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

370 THE BRITISH JOURNAL OF OPHTHALMOLOGY which this diagnosis was established. The literature is reviewed- only five cases appear to have been reported-and these and the author's case are so similar in their main features that the following short summary of the condition as a clinical entity may be given. Aetiology.-Perforation of the cornea or sclera by a foreign body which has been retained in the eye. In each case this has been a fragment of iron and the injury occurred when iron was being chiselled; in three cases contamination with earth was probable. Bacteriology.-B.Welchii has been isolated in each case, strep- tococci and staphylococci have also been observed. Morbid Anatomy.-The orbital oedema is not infective but is secondarily due to the panophthalmtiis. There is a wound of the cornea or sclera; chemosis is intense, the cornea is hazy and the anterior chamber may contain hypopyon; the iris is inflamed and may show a reddish discoloration. The tension, if the wound is closed, is high. On section (Chaillous) all the contents of the globe are disorganised and there is engorgement of the retinal and chor- oidal vessels, round which very few bacilli are to be seen, these being found in great numbers in the more central parts; the cellular reaction consists of polymorphonuclear leucocytosis. Symptoms.-Early pain in the eye with loss of vision, followed by intense headache and collapse, which may be accompanied by vomiting. Temperature 1000-1020F. Onset of symptoms within

twelve to twenty-four hours. http://bjo.bmj.com/ Locally.-Great swelling of the lids and adjacent parts which are dark red in colour and very tender; proptosis and fixation of the eyeball; chemosis and all the signs of an acute panophthalmitis. A bubble of gas, increasing in size under observation for a few hours, may be seen in the anterior chamber. Glycosuria may be

present. on October 1, 2021 by guest. Protected copyright. Diagnosis.-From orbital cellulitis-the history, the general condition of the patient, the temperature, the early onset of symptoms and the intense orbital oedema, with proptosis and fixation of the eyeball, are suggestive of the nature of the infection. If gas is present in the anterior chamber the diagnosis is streng- thened; if the bubble of gas is seen to increase in size under observation it is confirmed. Treatment.-The treatment adopted in this case consisted in excision of the centre of the cornea followed by evisceration, insertion of a drainage tube and irrigation with saline, avoiding injury to the sclera and conjunctiva. After-treatment included frequent irrigation with hydrogen peroxide and the administration Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

THERAPEUTICS 371 of anti-gas-gangrene serum. A drainage tube was retained until all discharge from the globe had ceased. The patient recovered and left hospital in ten days. It is uncertai'n whether extension of the infection into the orbit is to be feared if the orbital tissues are opened at operation but it is suggested that the treatment oulined is safe and effective. Prognosis.-All cases have recovered. A. F. MACCALLAN.

V.-THERAPEUTICS

(i) Terrien, F. (Paris). -Ocular complications following the use of arseno-benzol compounds. (Des Complications oculaires apr!s l'emploi des Arsdno - benzols). Arch. d'Ophtal., September, 1929. (1) The toxicity of the arsenical preparations employed in the early days of intravenous medication of syphilis has resulted for some years in their replacement by less noxious compounds. In spite of this change, and acquired experience in the administration of these drugs, ocular complications are not uncommon. Terrien has observed a number of these' unfavourable results

in recent years, and this paper is based upon a clinical lecture given http://bjo.bmj.com/ to his students to afford them some knowledge of the possible risks of this method of treatment. Terrien considers these complications under two main headings: (1) Reactions which are purely toxic, affecting the normal eye and its adnexa, and shown chiefly by vaso-motor disturbance; they are not as a rule serious. (2) Early " specific reactions," by which he signifies reactions appearing -soon after one or two injections; on October 1, 2021 by guest. Protected copyright. they are reCognised to be of toxic origin, but are partially or wholly determined by specific lesions; they result perhaps from the sudden death of a large quantity of spirochaetes and the liberation of their toxins, or from an exacerbation of the virulence of spirochaetes preceding their destruction, or from crowding of them to the nerve centres when driven from the mucous and cutaneous tissues. The disappearance of the'symptoms on continuation of the injections shows the specific nature of these reactions. Their site may be the cornea, uveal tract, retina, optic nerve, and excep- tionally the motor nerves of the eyeball. The paper is long and interesting and the subject well discussed. In his resume Terrien urges great caution in the use of the arseno- benzols. He would reserve them for " certain forms of syphilis in Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

372 THE BRITISH JOURNAL OF OPHTHALMOLOGY which mercury seems to exert an insufficient effect, a happening which is unusual when the drug is well employed, especially by intravenous injection." The administration of the arseno-benzol preparation should be begun in small doses, 15 to 20 cgr., though even these amounts have given rise to grave crises. Finally if arseno-benzol medication is prescribed in cases of severe disease of the cornea or uveal tract which has proved resistant to other methods of treatment, it should never be employed if the optic tract is involved, particularly in the optic nerve affections of tabes; in such circumstances its use may be followed by rapid and severe aggravation of the disease. J. B. LAWFORD. (2) Muncy, William M. (Providence, R.I.)-The treatment of gonorrheal ophthalmia.-Jl. of Ophthal. Otol. and Laryn., August, 1929. (2) Muncy states that his only excuse for writing upon this topic is that during a practice of 21 years he has come to certain definite conclusions. It is the predilection of the gonococcus to burrow between the cells into the deeper layers of the mucous membrane that accounts for their destruction and the difficulty of treatment. Regarding actual methods of treatment the author commences by stating that nursing is not only the first, but the second and

third most important factor. http://bjo.bmj.com/ Careful examination is the first step, and this should be carried out by the physician or house surgeon. The extent of invasion, and any corneal involvement is to be noted. Desmarres retractors should be used, and these should be lightly greased or dipped in water. For cleansing purposes, cotton dipped in boracic acid and squeezed between the fingers thus releasing a liberal stream of solution upon the eyeball, is used. On no account is rubbing, or on October 1, 2021 by guest. Protected copyright. a dropper to be used. Actual treatment consists in irrigation of the conjunctival sac as fast as the material develops. This means in the active stage, every twenty minutes, increasing up to thirty minutes; later to be followed by hourly washings and when the discharge has abated, every two hours by day, anid three by night. If ice is used careful supervision should be exercised with regard to time employed. If the swelling of the lids is not controlled by ice in a few hours' application, then external canthotomy ought to be done. Regarding the employment of antiseptics he has found argyrol the best and safest. Strengths under 25 per cent. are useless and the drug should be in constant contact with the infected area for Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

IHERAPEUTICS 373 50 per cent. of the time. The preparation should be fresh and never used longer than fourteen days after preparation. Strengths. of 25 per cent. to 40 per cent. can thus be used and are non-irritating, The eye is flooded with argyrol which is allowed to remain 20, 30, 60 minutes or even 1-2 hours depending upon the amount of dis charge. After the next cleansing the eye is left free, until the next period when a fresh flooding is made. Thus whatever the frequency of cleansing the argyrol is present 50 per cent. of the time. If one eye only is affected the unaffected eye is treated with the same strength argyrol, three or four times in twenty-four hours. If on -the first examination grey exudate be noted on the cornea, however small, then milk injections or injection of similar proteid products (aolon) should be resorted to. UJnless there is much swelling of the lids heat should be resorted to. Pledgets of cotton wool wrung out in hot water should be applied every two minutes at thirty-minute intervals. If an adult then the daily application of act- inic rays from a quartz lamp is found to be most efficacious. This is applied by means of a quartz rod which is held W of an inch from the ulcer for 20 seconds. Then treat the limbus nearest to the ulcer for 30 seconds. After the treatment one or two minims of 2 per cent. acriviolet are dropped upon the ulcer. This is slightly painful and can be preceded by holocaine or butyn. Cocaine must not be used. The acriviolet is applied once or twice daily. A case is described of a woman aged 70 years, who contrActed the disease from a grandchild. An annular ulcer of the cornea was present. Treatment consisted in argyrol 35 per cent., hot applica- http://bjo.bmj.com/ tions, and acriviolet. Milk injections were negative in this case. The result was excellent. Attention is also drawn to the use of argyrol as a preventive measure in the newly born in place of the Crede method of 2 per- cent. silver nitrate. The eyes are flooded with 35 per cent. argyrof which is allowed to stay for two hours. This to be repeated on second and third day. No infections have followed this treatment. on October 1, 2021 by guest. Protected copyright. The author does not state how long this technique has been in force. He closes by impressing the fact that 75 per cent. of the care is nursing leaving argyrol in strong fresh solution flooded into the conjunctival sac 50 per cent. of the time, to do the rest. S. SPENCE MEIGHAN. (3) Lemoine, A. N. (Kansas City, Mo.)-Ocular anaphylaxis. Arch. of Ophthal., June, 1929. (3) Lemoine's paper opens with a brief survey of the work done on this subject, which was started by Uhlenhuth in 1903 when he showed that animals could be sensitised and immunised with lens Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

374 THE BRITISH JOURNAL OF OPHTHALMOLOGY protein and that this hypersensitivity was tissue specific and not species specific. Elschnig showed the same thing with regard to uveal pigment in 1916 and suggested an allergic basis for sympa- thetic ophthalmitis, a suggestion which was elaborated by Alan Woods. Later Igersheimer laid down an anaphylactic basis for interstitial keratitis. Other lesions of the eye which have been attributed to anaphylaxis, comprise phlyctenular disease, recurrent intra-ocular haemorrhages and intra-ocular inflammations following rupture of the lens capsule (phako-anaphylactic endophthalmitis) also certain types of conjunctivitis, notably spring catarrh and a case of keratitis in a patient who proved to be hypersensitive to ,corn and was cured by desensitisation. The author then refers to ,a number of cases of his own. Thus: six patients who had conjunctivitis each summer were found to be sensitive to pollens, and the same was true of four cases of old trachoma who had recurrences each summer. One patient was hypersensitive to face powder and ,developed conjunctivitis from this cause, while of two cases of recurrent dendritic ulcer, one was found to be sensitive to chocolate and the other to pollens. Another interesting case was that of a man who had frequent attacks of diplopia with severe vertigo and teichopsia but no headache. The attacks ceased on removal of cheese from his diet and he never had another attack except after eating this food. There is another point, however, in the treatment of allergy, namely that the condition is often associated with endo- crine imbalance, the thyroid, parathyroids and gonads being the

glands most frequently Involved. Thus the author has successfully http://bjo.bmj.com/ treated some cases of spring catarrh by the administration of thyroid, parathyroid and calcium. F. A. W.-N. (4) Beigelman, M. N. (Los Angeles).-The untoward effects of protein therapy in ophthalmic practice. California and Western Medicine, p. 404, June, 1929. on October 1, 2021 by guest. Protected copyright. (4) In this paper Beigelman discusses the dangers of protein therapy which treatment he has extensively used. Local complications are the results of imperfect technique but general and focal complications are more difficult to understand. Anaphylactic reactions are not common enough to warrant sensitization tests in each case and are usually well controlled especially with adrenalin. The focal results of protein injection are not sufficiently understood yet but in cases where the part of repair is very low the injection may precipitate the most intense exacerbation in the inflammation under treatment. In spite of untoward results he in no way discredits the value of protein injections. R. C. DAVENPORT. Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

GLAUCOMA 376 VI.-GLAUCOMA (i) Calhoun, F. Phinizy (Atlanta, Georgia). -The vascular state and glaucoma. Amer. Ji. of Ophthal., April, 1929. (1) Calhoun examined 64 patients with glaucoma in order to test the veracity of Charlin's observation that 90 per cent. of these cases show general vascular symptoms and that syphilis is almost always present in cases under 50 years of age. His conclusions were: (1) Vascular disease was present in 95 per cent. of cases. (2) Syph- ilis was present in 15 per cent. of the vascular cases and in 14 per cent. of all cases, and nephritis in 40 per cent. and 37 per cent. respectively. (3) Abnormally high systolic pressure present in 42 per cent. and diastolic in 57 per cent. (4) Dilatation of the heart or aorta was present in 60 per cent. These observations lead the author to support Maitland Ramsay's suggestion that glaucoma and glomerular nephritis are both due to a toxin which produces dilatation of the capillaries and increased permeability of their walls. F. A. W.-N. (2) Schoenberg, Mark J. (New York).-The artificial induction of ocular hypertension by compression of the jugular veins. Arch. of Ophthal., June, 1929. (2) Schoenberg was induced to carry out the work detailed in this paper by the following experience. A patient had a tonometer applied to his eye with a 7.5 gramme weight. The pointer was deflected to the 6th division. Within a few seconds it had moved http://bjo.bmj.com/ to the 5th and then to the 4th division. Schoenberg noted that the patient was sitting with his head bent so far back that his tight collar had produced a mild strangulation of his jugular veins, and his face was cyanotic. He therefore ascribed the rise of intra-ocular pressure to venous engorgement, and devised an apparatus for pro-

ducing this condition in varying degrees. It consisted of a on October 1, 2021 by guest. Protected copyright. sphygmomanometer cuff, fitted with hooks and eyes so that it could be fastened round the neck and inflated, thus exerting pressure on the jugular veins. Three main types of reaction were obtained. In the first, the pressure rose during jugular compression and returned to normal after its release; in the second, it went down to lower than the initial figure after release of pressure; while in the third type, application of pressure to the jugular veins produced no alteration in intra-ocular tension. F. A. W.-N. (3) Inman, W. S. (Portsmouth).-Emotion and acute glaucoma. Lancet, December 7, 1929. (3) It is difficult to give an abstract of Inman's short article, since, aside from the record of one particular and very suggective Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

376 THE BRITISH JOURNAL OF OPHTHALMOLOGY case, it contains a good deal of speculative matter which is not easy to synopsise. Briefly, Inman's suggestion is that while it is generally agreed that emotion as ordinarily understood may be the exciting cause of an attack of glaucoma, it may evern be possible that " the onset may coincide with the anniversary of events once pregnant with emotion but now apparently indifferent or even long since forgotten." The author goes on to say, " The psychological investigation of suclh cases might lead to a further knowledge of the mechanisms involved, and so enable us sometimes to prevent .the development of this very serious and painful disease by pro- viding for the discharge of the emotion through legitimate paths." The reviewer confesses that he does not understand what is meant by " legitimate paths." He is not a psychologist and so may be quite mistaken in thinking that in order to lead a subconscious emotion along any path at all it would be only possible to do so at the risk of bringing the emotion acutely forward into consciousness. However that may be the case recorded is of interest, and should be read in the original. It cannot usefully be abbreviated. Further, the author is working at the subject more fully and it is hoped there may be other articles to follow. ERNEST THOMSON. (4) Cantonnet, A. (Paris).-Ionisation in glaucoma. (l'Ionisation dans le glaucome.) La Clin. Ofhtal., October, 1928.

(4) Cantonnet's article is not one which seeks to prove the http://bjo.bmj.com/ fact or to discuss the details of ionisation in the case of the eye. It assumes as common knowledge that " medicamentous substances" penetrate the eye to such an extent that they can be found in traces in the urine. lonisation of the eye reduces tension, temporarily it is true. The author has found it very useful in glaucoma, prin- cipally as a means of reducing the tension prior to operation in acute and subacute glaucoma. He employs chloride of calcium: on October 1, 2021 by guest. Protected copyright. the details are here given in French in order to avoid possibility of mistake in translation:-" chlorure de calcium 1/400, intensit6 1 a 2/5 de milliampere " for 20 to 30 minutes, three or four times per day before opening the eyeball. In this way one can reduce the tension from 70 to 45 or 50 millimetres of mercury and thus operate under the best conditions. Then there are cases of acute glaucoma where operation is refused, and in such a case Cantonnet was able by means of pilocarpine and ionisation to reduce the tension and maintain " satisfactory " vision for three years. In chronic glaucoma, when operation is refused or when it is contraindicated the procedure is as follows: " one gives ionisation seances of chloride of calcium if the tension is distinctly above normal, while iodide of sodium is employed if the tension is normal Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

GLAUCOMA 377 or nearly so, in order to act upon the sclerosis rather than upon the tension." These ionisations are repeated every 4, 5 or 6 days so as to keep the eye in a favourable condition. The author is very careful to point out that he is not advocating ionisation as a substitute for operation. Where operation is decided upon and accepted; ionisation is a preparatory treatment. Only where operation is refused, or is contraindicated, does ionisation become a treatment per se. ERNEST THOMSON. (5) Birch-Hirschfeld (Konigsberg).-Tonometry in the diagnosis and the following up ofglaucoma cases. (Zur tonometrischen Beurteilung des Glaukoms).- Zeitschr. f. Augenheilk., Vol. LXX, p. 1, 1929. (5) Birch-Hirschfeld relates his experience of three years' work on carefully recording the tonometric variations in over a hundred glaucoma cases. Readings were taken in these cases three times a day, at seven o'clock in the morning, at noon and in the evening. As is well known there is a considerable diurnal variation in the tension of the normal eye and according to Birch-Hirschfeld a disturbance in the normal rhythm of these variations is a symptom that precedes any other in glaucoma; the healthy eye gives variations akin to those of the temperature of the healthy body, whilst the fluctuations in the glaucomatous eye are more like the hectic fluctuations seen in a septic infection. In absolute glaucoma these hectic fluctuations may disappear, the tension remaining at a uni- form high level, a parallel to the continuously high temperature http://bjo.bmj.com/ sometimes seen in pneumonia. rhe use of miotics may favourably affect the fluctuations seen in glaucoma, but such effects are not necessarily permanent; it often happens that the hectic fluctuations typical of glaucoma return after a time. This should be considered a strong indication for operative interference. The return to normal after miotics or operation may be either by " crisis " or " lysis." on October 1, 2021 by guest. Protected copyright. A point of considerable interest is the parallelism of the tension- charts of the two eyes. This is a process seen in normal eyes and persists in glaucoma, even when only one eye is affected. In such cases the sound eye will follow all the excursions, including any irregularities, of its glaucomatous partner, though of course, not to the same extent. This applies to primary glaucoma; in secondary glaucoma no such parallelism exists: the curves may even overlap, and this may also happen sometimes for a limited period after operation. Birch-Hirschfeld sees in this parallelism an argument in favour of a centre controlling ocular tension. The parallelism in the tension of the two eyes has a practical application, for the author has more than once avoided an operation on a definitely glaucomatous eye, by performing a decompression operation on Br J Ophthalmol: first published as 10.1136/bjo.14.7.359 on 1 July 1930. Downloaded from

378 THE BRITISH JOURNAL OF OPHTHALMOLOGY a practically blind fellow eye. The better eye shares the improve- ment in tension that the operation achieves in the worse eye; tonometric measurements clearly bring out the more regular variations in tension in both eyes as a result of an apparently needless operation. " Tonometric measurements will become as indispensable in the treatment of glaucoma as the taking of the bodily temperature is in infectious diseases." ARNOLD SORSBY.

BOOK NOTICES Handbuch der speziellen pathologischen Anatomie und Histologie. Auge. Erster Teil. Editor: K. Wessely. Con- tributors: G. Abelsdorf, A. Elschnig, S. Ginsburg, R. Greeff, E. v. Hippel, W. Lohlein, F. Schieck. Berlin: Julius Springer. 628 illustrations. Pp. 1,042. Two volumes of this System of Pathology are to be devoted to the pathological anatomy of the eye, and the book under review is the first of these. It comprises sections dealing with the conjunctiva, the cornea, the uveal tract, the retina, the optic nerve, the vitreous and glaucoma respectively, for each of which a difterent author is responsible. With trifling variations a similar arrangement of the

subject matter is followed by each, a division of the material into http://bjo.bmj.com/ subsections on a partly anatomical basis and a partly clinical one, having been adopted. As the title implies, histological pathology is maitnly dealt with, but some theoretical questions are briefly discussed-for example, the causes of retinal detachment and of glaucoma. Bacteriology is included where its discussion is appropriate, and in some instances technical advice is given as to the best method of on October 1, 2021 by guest. Protected copyright. preparing the tissue under discussion for examifiation, while each of the first six sections opens with a description of the normnal histology of that particular part of the eye. Slit-lamp observations are briefly referred to here and there, but the correlation of slit-lamp and microscopic findings is not a feature of the book. At the end of each section a full bibliography is appended, and the general index leaves nothing to be desired in completeness. The illustrations are numerous and excellent; the great majority of these are reproduced from drawings, many of them coloured, and there are also a few microphotographs. The actual text consists of a series of short r6sumes of the work of different authors of all nationalities (up to 1925 inclusive) the name of each being mentioned, and these resumes are interspersed